Urological Manifestations of Placenta Percreta

Reloadable Stapler Use during Peripartum Hysterectomy for Placenta Accreta Spectrum: A Novel Surgical Technique and Case Series

OBJECTIVE

This study aimed to describe a novel surgical technique for the management of antenatally suspected placenta accreta spectrum (PAS).

STUDY DESIGN

This is a retrospective, case series of patients with suspected PAS undergoing peripartum hysterectomy with a reloadable articulating stapler at a tertiary care center.

RESULTS

Eighteen patients with antenatally suspected PAS were identified and underwent peripartum hysterectomy with the aid of a reloadable stapler. Mean gestational age at delivery was 34^4/7 ± 1^1/7 weeks. Mean total operative time (skin-to-skin) was 117.3 ± 39.3 minutes, and 79.8 ± 19.8 minutes for the hysterectomy. Mean blood loss for the entire case was 1,809 ± 868 mL. Mean blood loss for the hysterectomy was 431 ± 421 mL. Mean units of intraoperative red blood cells transfused was 3 ± 1 units. Mean units of postoperative red blood cells transfused was 1 ± 0.5 units. Five cases were complicated by urological injury (two intentional cystotomies). Four patients were admitted to the intensive care unit (ICU) for a mean of ≤24 hours. Mean postoperative LOS was 4.11 ± 1.45 days. Three patients had final pathology that did not demonstrate PAS while four were consistent with accreta, six increta, and five percreta.

CONCLUSION

Use of a reloadable articulating stapler device as part of the surgical management of antenatally suspected PAS results in a shorter operative time (117 ± 39 minutes vs. 140-254 minutes previously reported), lower average blood loss (1,809 ± 868 mL vs. 2,500-5,000 mL previously reported) and shorter LOS (4.11 ± 1.45 days vs. 9.8 ± 13.5 days previously reported) compared with traditional cesarean hysterectomy. The reloadable stapling device offers an advantage of more rapidly achieving hemostasis in the surgical management of PAS.

KEY POINTS

· PAS is associated with severe maternal morbidity.. · Decreased operative time and blood loss have many clinical benefits.. · Reloadable stapler use for PAS decreases operative time.. · Reloadable stapler use for PAS decreases operative blood loss..

Risk Factors for Urological Complications Associated with Caesarean Section—A Case-Control Study

Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify the risk factors for urologic injuries at CS in order to inform obstetricians and patients of the risks and allow management planning to mitigate these risks. Materials and Methods: We reviewed all cases of urological injuries that occurred at CS surgeries in a tertiary university centre over a period of four years, from January 2016 to December 2019. To assess the risk factors of urologic injuries, a case-control study of women undergoing caesarean delivery was designed, matched 1:3 to randomly selected women who had an uncomplicated CS. Electronic medical records and operative reports were reviewed for socio-demographic and clinical information. Descriptive and univariate analyses were used to characterize the study population and identify the risk factors for urologic complications. Results: There were 36 patients with urologic complications out of 14,340 CS patients, with an incidence of 0.25%. The patients in the case group were older, had a lower gestational age at time of delivery and their newborns had a lower birth weight. Prior CS was more prevalent among the study group (88.2 vs. 66.7%), as was the incidence of placenta accreta and central praevia. In comparison with the control group, the intraoperative blood loss was higher in the case group, although there was no difference among the two groups regarding the type of surgery (emergency vs. elective), uterine rupture, or other obstetrical indications for CS. Prior CS and caesarean hysterectomy were risk factors for urologic injuries at CS. Conclusions: The major risk factor for urological injuries at the time of CS surgery is prior CS. Among patients with previous CS, those who undergo caesarean hysterectomy for placenta previa central and placenta accreta are at higher risk of surgical haemostasis and complex urologic injuries involving the bladder and the ureters.

Urological issues in pregnancy: A review for urologists

Urological issues in the pregnant patient present a unique clinical dilemma. These patients may be challenging to treat due to risks associated with medications and surgical procedures. This review aims to provide an update on the physiological changes and surgical risks in pregnancy. In addition, we review the approach for management of urolithiasis and urinary tract infections in pregnancy. Lastly, we highlight the importance of a multidisciplinary approach to placenta percreta, a condition not commonly addressed in urological education.

Emergency peripartum hysterectomy at Jordan University hospital - a teaching hospital experience

Introduction

Emergency peripartum hysterectomy (EPH) is a foremost operation and is perpetually implemented in the presence of life intimidating hemorrhage during or immediately after abdominal or vaginal deliveries. The aim of this study was to review cases managed at the Department of Gynecology and Obstetrics at Jordan University Hospital (JUH).

Material and methods

All women who underwent EPH due to any cause in the period from January 2010, to December 2017 were included in the study. Data were collected retrospectively using the patients’ files namelessly. Main measures: age, gravidity, parity, number of previous cesarean sections, previous uterine surgeries, indication for hysterectomy, complications, antepartum bleeding and the need for blood transfusion.

Results

In total, 74 cases of EPH were managed during the study period. The incidence of EPH ranged from 0.24 to 8.7 per 1000 deliveries. EPH was found to be more common following cesarean sections than vaginal deliveries. The prime indication was abnormal placentation, uterine atony, and uterine rupture. The risk factors included previous cesarean sections, scarred uteruses, multiparity, older age group. Maternal morbidity ranged from 26.5 to 31.5% and mortality from 0 to 12.5% with a mean of 4.8%.

Conclusions

EPH is the most demanding obstetric surgery performed in very tiresome circumstances of life threatening hemorrhage. The indication for EPH in recent years has changed from outdated uterine atony to abnormal placentation. Antenatal eagerness of the risk factors, engrossment of proficient obstetricians at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in tumbling morbidity and mortality.

Placenta percreta with bladder invasion: The armamentarium available in its management

Placenta percreta is a rare life-threatening condition associated with high morbidity and mortality due to severe obstetric hemorrhage. It can be associated with bladder invasion which leads to hematuria. Treatment is decided on a case-to-case basis, and there have been no guidelines proposed so far. Strategies include obstetric hysterectomy, leaving the placenta in situ with postoperative methotrexate therapy and removal of the placenta with bladder reconstruction in a single stage. An unusual case of a patient with placenta percreta and bladder invasion who presented with delayed hematuria after the placenta was left in situ has been reported. The patient was managed conservatively for 10 days postdelivery after which a decision to do an obstetric hysterectomy with focal cystectomy was taken in view of persistent hematuria. An algorithm for managing cases of placenta percreta with bladder invasion has been proposed to manage these difficult situations.

Interval Hysterectomy for Placenta Percreta - a Case Report

INTRODUCTION

Placenta percreta is an abnormality of placentation where it invades the serosa and can go beyond it. Complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. The aim of this study is to report a complex case of placenta percreta managed by interval hysterectomy.

CASE PRESENTATION

Pre-operative: 34 years old patient with previous three cesarean sections was followed in antenatal clinic. She came with repeated bouts of vaginal bleeding at 30-31 weeks. At 32 weeks and 4 days classical cesarean section was done with placenta left in situ. Prophylactic bilateral internal iliac artery balloon was inserted. Post cesarean section, uterine artery embolization was performed. Post-operative: Clinical features of pulmonary embolism (PE) developed about 4 hours later. Post-Operative Day 13: Total abdominal hysterectomy was done. After few days of discharge, the patient presented to the emergency department with shortness of breath. She was consequently diagnosed with chronic pulmonary embolism and treated with warfarin.

CONCLUSION

This is a case of placenta percreta managed by interval hysterectomy. However, the most widely accepted method of management is cesarean hysterectomy. In this case, interval hysterectomy was done due to the possibility of bladder invasion by placenta, to decrease the amount of blood loss and to reduce the number of days stayed in hospital. Appropriate management for the patient must be personalized, whether it is by cesarean hysterectomy or interval hysterectomy, as each has risks and benefits.